Senara provides copies of our intake form(s) online for our new Medical Weight Loss Center guests. Available as downloadable PDFs, you may fill out your intake form at your convenience before your first visit with us.
If you have not scheduled your initial appointment yet, please call 309.693.9600 prior to filling out the form.

Medical Weight Loss Printable Forms

To download and print your intake form, please follow these steps:

Email us your completed forms, or, you can print and send your forms to us at this mailing address.

Medical Forms & Records

Medical Weight Loss guests may submit their Medical History Form at the time of their initial appointment. Additionally, guests seeking Medical Weight Loss care do not need to provide prior medical records, though may bring them to their initial appointment if deemed necessary.
If you have medical records that are pertinent to your initial visit or follow-up visits, you are responsible for obtaining them prior to that appointment. Your Medical Records can only be authorized for release by you. Please contact your physician or other health care provider to order these records.
All Medical Forms and Records should be submitted to us via one of the following options:

  • Fax: 309.693.3616
  • Mail: Attn: Dr Keith Kramer, 2208 W Willow Knolls Rd, Peoria, IL 61614
  • E-mail:
  • Drop off to the front desk staff at Senara

*These statements have not been evaluated by the Food and Drug Administration. This information is for educational purposes only and is not intended to diagnose, treat, prevent or cure any disease.  These products and services are intended to support, not replace, your current medical care. Individual result may vary.